What is the best course of action for an elderly man with a reducible inguinal hernia that causes mild discomfort without significant pain, which bulges when coughing or standing but reduces when lying down?

Surgical Repair is Recommended for This Elderly Patient with Reducible Inguinal Hernia

For an elderly man with a reducible inguinal hernia causing symptoms (bulging with coughing/standing, mild discomfort), elective surgical repair with mesh is the recommended treatment approach. While the hernia is currently reducible and symptoms are mild, the natural history demonstrates that the majority of patients with symptomatic inguinal hernias will eventually require surgery, and delaying repair increases the risk of emergency presentation with incarceration or strangulation, which carries significantly higher morbidity and mortality 1, 2.

Why Surgery Over Conservative Management

The "watchful waiting" strategy is only appropriate for truly asymptomatic or minimally symptomatic hernias 1, 3. This patient has clear symptoms:

• Visible bulging with increased intra-abdominal pressure (coughing, standing)
• Mild discomfort that is bothersome enough to prompt medical evaluation
• These symptoms indicate the hernia is already impacting his quality of life 4

The risk of life-threatening complications from groin hernias in watchful waiting is low but not zero, and the majority of patients initially managed conservatively eventually require surgery anyway 3, 5. In elderly patients, elective repair under controlled conditions is significantly safer than emergency repair - one study showed 50% complication rate in emergency settings versus 8.6% in elective settings for patients over 75 years 6.

Optimal Surgical Approach for This Elderly Patient

Mesh repair is mandatory and should be performed electively 1, 2. The specific technique should be:

Choice Between Open vs Laparoscopic

• Laparoscopic repair (TEP or TAPP) is suggested as first-line if local expertise is available, offering reduced chronic postoperative pain, faster recovery, lower wound infection rates, and ability to identify occult contralateral hernias (present in 11.2-50% of cases) 1, 2, 5
• Open Lichtenstein repair under local anesthesia is an excellent alternative, particularly advantageous in elderly patients with cardiovascular/respiratory comorbidities, as it avoids general anesthesia risks and has fewer cardiac and respiratory complications 1, 6, 7

Anesthesia Selection

• Local anesthesia is strongly recommended for open repair in elderly patients, providing effective anesthesia with shorter hospital stays, lower costs, faster recovery, and fewer complications compared to general anesthesia 1, 7, 5
• General anesthesia is required only if laparoscopic approach is chosen 1
• In patients aged 65 and older, general anesthesia may be preferred over regional anesthesia as it is associated with fewer complications like myocardial infarction, pneumonia, and thromboembolism 5

Mesh Considerations

• Synthetic mesh is the standard in clean surgical fields (which this case represents), with 0% recurrence rate versus 19% with tissue repair alone 1, 2
• Mesh must overlap the defect edge by 1.5-2.5 cm 1

Why Not Lifestyle or Activity Modification Alone

Lifestyle and activity modifications do not address the underlying anatomical defect and will not prevent progression or eliminate symptoms 4. While patients should avoid heavy lifting and straining that exacerbate symptoms preoperatively, these measures are temporizing only and do not constitute definitive management 4. The hernia will not resolve spontaneously and symptoms typically worsen over time.

Timing and Setting

Day surgery is recommended for the majority of groin hernia repairs provided aftercare is organized 5. This patient's hernia is reducible without signs of incarceration or strangulation, making him an ideal candidate for elective outpatient repair 1, 6.

Elective repair should be scheduled at the patient's convenience but should not be indefinitely delayed, as the risk of developing incarceration/strangulation increases with time, and emergency repair carries 8-fold higher complication rates in elderly patients 6.

Critical Preoperative Assessment

Before surgery, careful evaluation is essential 6, 7:

• Cardiovascular and respiratory status assessment (common comorbidities in elderly)
• Identification of risk factors that might predict complications
• Discussion of realistic expectations regarding recovery and outcomes
• Confirmation that the hernia is truly reducible without signs of strangulation (no severe pain, no signs of bowel compromise) 2

Common Pitfalls to Avoid

• Do not delay repair indefinitely - while this is not an emergency, procrastination increases the risk of presenting with incarceration/strangulation, which dramatically increases morbidity and mortality in elderly patients 1, 8, 6
• Do not dismiss symptoms as "just mild discomfort" - symptomatic hernias warrant repair to prevent progression and improve quality of life 4, 5
• Do not overlook the possibility of contralateral hernia - if laparoscopic approach is chosen, the opposite side should be inspected 1, 2

Expected Outcomes

Inguinal hernia surgery in elderly patients is safe and effective in an elective setting 6, 7. Patients over 65 years have low complication rates when surgery is performed electively with appropriate anesthesia selection 6. Patients should be counseled to resume normal activities without restrictions as soon as they feel comfortable postoperatively 5.

Answer: A - Surgical repair is the correct management for this symptomatic, reducible inguinal hernia in an elderly patient.